Job Description

Description:
Clinical Documentation Specialist II Clinical Documentation Integrity

Primary Location St. Mary's Medical Center

Step into Florida The most sizzling state in the nation, where there is high tides and good vibes. Grow within an organization of support and superior patient care within Tenet Healthcare Hospitals. Our CDI program offers relocation assistance and sign on bonus to potential CDI candidates.

Position Summary: Under general supervision of the Clinical Documentation Integrity Program Manager, the Clinical Documentation Specialist II is responsible for improving overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physician, case management, nursing staff, other patient caregivers and coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician outcomes.

POSITION ACCOUNTABILITIES AND PERFORMANCE CRITERIA

1. Initiates and performs concurrent documentation review of selected inpatient records to clarify

conditions/diagnosis and procedures where inadequate or conflicting documentation is suspected. Meets or exceeds defined performance standards for chart reviews and queries.

2. Improves coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patients stay. This includes capturing complications/co-morbidities during the patients stay. This is achieved via queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal. Serves as a resource for physicians to help link ICD-10-CM coding guidelines and medical terminology to improve accuracy of final code assignment.

3. Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned base on documentation. Participates in educational programs and in-services in order to maintain and exceed excellence in coding skills.

Up to $7,500 Sign on Bonus available based on Experience

Qualifications:
POSITION QUALIFICATIONS: EDUCATION REQUIREMENT:

Required: Graduate of a foreign medical school or education recognized by the State of Florida, as qualification for licensed Registered Nurse, LPN, Physician Assistant, or Advanced Practice Registered Nurse

Desirable: MBA, MPH, MHA or MSN

REQUIRED LICENSURE/REGISTRATION/CERTIFICATIONS:

* Must be either: licensed in the State of Florida as a Registered Nurse, LPN, Physician Assistant or APRN licensed in the State of Florida or a graduate of a foreign medical school (with ECFMG Certification preferred but not required)
* Certified in one of the following within 2 years of hire into the position:
* Certification in clinical documentation improvement through ACDIS or AHIMA (CCDS or CDIP) strongly desired.
* Certified in coding (CCS) preferred.

EXPERIENCE:

Minimum of 2 years clinical or inpatient experience in an acute care setting required; 5 years strongly preferred.

Full Time Days

LI-JW1

Job: Medical Records

Primary Location: Delray Beach, Florida

Facility: Delray Medical Center

Job Type: Full-time

Shift Type: Days

Employment practices will not be influenced or affected by an applicants or employees race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

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